Traumatic eye injuries

The eye is a highly sensitive organ that is well-protected by the bony orbit and eyelid. Common traumatic eye injuries occur through blunt or sharp objects or chemical burns. Closed globe injuries usually follow blunt trauma and have a varied clinical presentation (superficial corneal abrasion to retinal hemorrhage). Open globe injuries usually follow sharp or high-velocity blunt trauma and present with ocular volume loss or a prolapsing uvea in addition to the sequelae of closed ocular injuries. Orbital floor fractures are a type of periocular injury following high-velocity blunt trauma to the globe and upper eyelid which present with unilateral periorbital pain, edema, and/or ecchymosis, enophthalmos, and an orbital rim “step-off” which is confirmed by CT. Chemical burns of the eye present with ocular pain, erythema, and blepharospasm. Treatment of traumatic eye injuries depends on the precise underlying injury. Chemical burns require immediate and adequate irrigation with water beginning prior to hospitalization. Urgent stabilization, antibiotics, and immediate ophthalmologic consultation is often required to rule out serious injury (e.g., severe chemical burns, open globe injuries, retinal detachment, extraocular muscle entrapment) and determine the need for surgery.

• Definition: closed globe injury which occurs in the absence of a full thickness ocular wall laceration or rupture ^[2]
• Mechanism of injury: blunt trauma
• Clinical features
  • Early sequelae
    • Conjunctival and corneal abrasion (sensation of foreign body in eye)
    • Ecchymosis
    • Retinal detachment
    • Lens dislocation
    • Hyphema: anterior chamber hemorrhage
    • Subconjunctival, vitreous, or retinal hemorrhage
    • Conjunctival or partial thickness laceration of the cornea or sclera
    • Rupture of the cornea or root of the iris (iridodialysis), mydriasis, iritis
    • Commotio retinae (Berlin edema)
      • Definition: traumatic edema of the macula and retina following ocular contusion
      • Clinical features: decreased vision a few hours after the injury
      • Diagnosis: fundoscopy showing retinal swelling and whitish clouding with possible bleeding ^[3]
      • Prognosis/Complications: usually resolves in 3–4 weeks without treatment.
  • Late sequelae
    • Retinal detachment
    • Subsequent vision loss
    • Glaucoma
    • Contusion cataract
• Diagnostics
  • Fundoscopy
  • Fluorescein stain to determine corneal abrasions and/or foreign bodies
• Treatment
  • Frequent ophthalmologic assessment
  • Eye immobilization if necessary (with a binocular bandage)
  • Specific treatment depends on the precise injury
  • Because of the risk of retinal detachment, ophthalmological follow-up is necessary for the rest of the patient's life.

• Definition: full-thickness perforation or laceration of the ocular globe
• Mechanism of injury: sharp objects or high-velocity blunt objects
• Clinical features
  • Gross deformity of the eye (ocular rupture with fluid volume loss) or prolapsing uvea (full-thickness laceration)
  • Afferent pupillary defect and impaired visual acuity
  • Eccentric or teardrop pupil
  • All sequelae of ocular contusion are possible (see above).
• Diagnostics
  • Careful investigation of the anterior and posterior segment of the eye (by slit lamp and fundoscopy, respectively)
  • Fluorescein stain if inconclusive: corneal abrasions and foreign bodies
  • Nonenhanced CT can be used if the eye cannot be directly visualized or to exclude the possibility of an intraocular foreign body.
  • Culture of the vitreous if a foreign body or infection is suspected
• Treatment ^[4]
  • Urgent stabilization and resuscitation
  • Analgesia (e.g., IV morphine), antiemetics (e.g., IV ondansetron), and tetanus vaccine or booster
  • Systemic antibiotic therapy for foreign bodies
  • Urgent ophthalmologic consultation for surgical repair
• Complications ^[5]
  • Permanent vision loss
  • Loss of eye
  • Endophthalmitis: inflammation of the tissues or fluid inside the eye (especially with retained intraocular foreign bodies), often presenting with deep ocular pain, a red eye, and reduced visual acuity
  • Sympathetic ophthalmia: bilateral granulomatous panuveitis after unilateral penetrating injury (and rarely after intraocular surgery) → bilateral blindness may occur

Avoid topical ointments in the presence of open globe injuries.

• Definition: Orbital contents are typically forced through a fractured orbital floor (blowout fracture).
• Mechanism of injury: high-velocity blunt trauma to the globe and upper eyelid (e.g., from a punch, tennis ball, etc.) that causes an indirect downward force to the infraorbital groove
• Clinical features
  • Unilateral periorbital pain, edema, and/or ecchymosis
  • Enophthalmos or proptosis
  • Orbital rim “step-off”
  • Restricted ocular movement can lead to diplopia: If the orbital tissue is prolapsed inferiorly, upward gaze is impaired
  • Loss of sensitivity in the area innervated by the infraorbital nerve
  • Epistaxis
  • Orbital emphysema or crepitus if the fracture involves the sinuses
  • Afferent pupillary defect and impaired visual acuity
• Diagnostics
  • Visual inspection for any global injury, e.g., hematoma, globe rupture, hyphema (see sections above and below)
  • CT or x-ray after ruling out any life-threatening or serious injuries (brain or spinal cord injury)
    • Muscle entrapment and/or edema
    • Tear drop sign on x-ray: prolapsed orbital tissue (e.g., fat, connective tissue septa, rarely the inferior rectus muscle) in the sinuses inferiorly
    • Bleeding into the sinuses
• Treatment
  • Urgent stabilization and resuscitation
  • Immediate ophthalmologic consultation for globe injuries or vagal symptoms (e.g., nausea, vomiting, bradycardia)
  • Conservative measures
    • Antibiotic prophylaxis
    • Oral corticosteroids to reduce swelling
    • Topical vasoconstrictor for epistaxis
    • Nasal decongestants and avoiding nose blowing
    • Preventative counseling

• Definition: chemical burn of the eye with acidic or alkaline substances
• Clinical features
  • Intense pain
  • Visual impairment
  • Blepharospasm: involuntary eyelid closure
  • Erythematous conjunctiva or whitening of the conjunctiva
  • Photophobia
• Treatment
  • Immediate and thorough irrigation with copious sterile saline (preferred if available) or cold tap water
  • Continued irrigation in the emergency department (ED) with a plastic scleral lens until the pH normalizes for acidic agents or for 2–3 hours for alkaline agents
  • Mechanical removal of solid particles that become acidic or alkaline when combined with water, e.g., dry lime
  • Antibiotic eye drops (e.g., tetracycline), broad-spectrum topical antibiotics (e.g., erythromycin ointment)
  • Ophthalmologic consultation
  • Topical glucocorticoids (e.g., prednisolone acetate 1%)
• Complications
  • Blindness
  • Scarring, clouding, and/or ulceration of the cornea
  • Neovascularization of the cornea
  • Symblepharon: adhesion of the eyelid (palpebral conjunctiva) to the globe (bulbar conjunctiva)

Patients should be advised to irrigate with a copious volume of water or saline for at least 15 minutes before arrival to the ED because immediate irrigation is the most important factor in preventing morbidity.

• Mechanism of injury: blunt or penetrating trauma
• Classification ^[6]
  • Simple: superficial eyelid laceration
  • Complex: laceration involving the eyelid margin, canalicular system, and/or canthal tendons
• Diagnostics
  • Visual inspection to exclude any global injury before examination and treatment of eyelid trauma (for more information see “Open globe injuries” and “Orbital floor fracture”)
  • Plain CT to rule out suspected intraocular foreign object
• Treatment
  • Laceration repair (see “Primary wound closure”)
    • Administer local anesthesia and use a protective scleral shell over the affected eye.
    • Clean the laceration and irrigate with water, normal saline, or povidone-iodine solution prior to closure.
  • Antibiotic treatment and rabies post-exposure prophylaxis for high-risk bite wounds
  • Tetanus prophylaxis

Complex lacerations require repair by an ophthalmologist or oculofacial plastic surgeon.